Bones, muscles, glands, and even the brain can function without immediate danger if they fail, but the kidneys are critical. If kidney function fails, the functions of bones, muscles, and the brain cannot be maintained. The timing of starting dialysis for patients with chronic kidney disease is an important decision with implications for patients' lives and costs. Guidelines recommend considering starting dialysis when the weekly kidney clearance of urea falls below 2.0, unless the patient's weight is stable and they lack symptoms of kidney failure.
When to dialyse a patient and with what modality of dialysis will be topic of discussion.The recent advances and debates surrounding the topic will be discussed in detail
When to dialyse a patient and with what modality of dialysis will be topic of discussion.The recent advances and debates surrounding the topic will be discussed in detail
Historical background
The concept of incremental dialysis
The residual kidney function and its significance
Incremental hemodialysis
Observational studies on incremental HD
The candidates for incremental HD
The potential benefits and risks associated with incremental HD
Incremental peritoneal dialysis
The intact nephron hypothesis in reverse
Renal Replacement Therapy: modes and evidenceMohd Saif Khan
Renal replacement therapy is a supportive care often required in critically ill patients who develop acute renal failure and its complications. Complexity arises when such patients become hemodynamically unstable and pose special challenge to critical care clinicians in ICU to carefully choose dialytic modality to tackle volume and solute overload. This presentation is about short description of modalities of RRT and current evidence regarding initiation, dose and type of modality.
A basic and worth information for diagnostic is urine microscopy. ideally it should be by the physician at his clinic to add and correlate diagnosis promptly. this will make physician confident in dealing with patients. it also help in follow up the consequences in some important glomerulopathies.
Historical background
The concept of incremental dialysis
The residual kidney function and its significance
Incremental hemodialysis
Observational studies on incremental HD
The candidates for incremental HD
The potential benefits and risks associated with incremental HD
Incremental peritoneal dialysis
The intact nephron hypothesis in reverse
Renal Replacement Therapy: modes and evidenceMohd Saif Khan
Renal replacement therapy is a supportive care often required in critically ill patients who develop acute renal failure and its complications. Complexity arises when such patients become hemodynamically unstable and pose special challenge to critical care clinicians in ICU to carefully choose dialytic modality to tackle volume and solute overload. This presentation is about short description of modalities of RRT and current evidence regarding initiation, dose and type of modality.
A basic and worth information for diagnostic is urine microscopy. ideally it should be by the physician at his clinic to add and correlate diagnosis promptly. this will make physician confident in dealing with patients. it also help in follow up the consequences in some important glomerulopathies.
When to Initiate RRT in Patients with AKI - Does Timing Matter?Apollo Hospitals
Acute kidney injury is a serious illness which occurs commonly in the renal units and also in the ICU setting. It is an independent risk factor of increased mortality and morbidity, particularly when RRT is needed. The wide variation in utilization of RRT contributes to a lack of consensus among clinicians regarding the parameters which should guide the decision to initiate RRT.
When to Initiate RRT in Patients with AKI - Does Timing Matter?Apollo Hospitals
Acute kidney injury is a serious illness which occurs commonly in the renal units and also in the ICU setting. It is an independent risk factor of increased mortality and morbidity, particularly when RRT is needed. The wide variation in utilization of RRT contributes to a lack of consensus among clinicians regarding the parameters which should guide the decision to initiate RRT. This problem is confounded by a paucity of high quality evidence in the current literature. This review examines the role of usual biochemical parameters as well as conventional clinical indications for commencing RRT. It also discusses the potential role of biomarkers as predictors for the need of RRT in AKI. Initiating dialysis in AKI should be based on dynamic clinical criteria and not only on specific biochemical values.
A ppt about contrast nephropathy: basics, risk factors, comparison of preventive strategies.
critical review of POSEIDON trial and brief about PRESERVE trial.
IMPORTANCE: Optimal timing of initiation of renal replacement therapy (RRT) for severe acute kidney injury (AKI) but without life-threatening indications is still unknown.
OBJECTIVE: To determine whether early initiation of RRT in patients who are critically ill with AKI reduces 90-day all-cause mortality.
Anaesthesia for Living Donor Combined Liver Kidney TransplantationApollo Hospitals
Orthotopic liver transplantation is now the best therapeutic option for patients with chronic liver failure [1]. Liver transplant is now a routine surgery performed in numerous medical centers throughout the world. Till now about 600 liver transplants have been performed in the Indraprastha Apollo Hospital, New Delhi. Combined liver kidney transplantation (CKLT) is the treatment for end-stage liver and kidney diseases. Combined liver kidney transplantation from living donors is performed in very few centers. Not many cases of Living donor combined Liver Kidney transplantation has been described in the literature. Here we report the clinical experience of our first living donor combined liver kidney transplantation (kidney after liver) in patient with end-stage liver disease (ESLD) and end stage renal failure (ESRD). Liver and kidney graft has been harvested from two living related donors.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
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Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
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micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
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early vs late dialysis
1. Bones can break, muscles can atrophy,
glands can loaf, even the brain can go to
sleep without immediate danger to
survival.
• But not!... should kidneys fail.... neither
bone, muscle, nor brain could carry on.
“Homer Smith”
4.
Most critical decision to make along the course of
chronic renal insufficiency.
Negative psychological impact on patients.
Important socioeconomic implications.
When to start - subject to much controversy.
3/18/2013
Dr. Abrar Ali Katpar@1st Nephrology
Symposium & Workshop on World
Kidney Day at KKH-Hail.
4
Initiation of dialysis.
5.
Free of uremic symptoms.
To control volume overload, acid-base and
electrolyte disorders.
And to provide a clearance of uremic toxins enough
to allow an adequate dietary protein and caloric
intake.
When residual renal function fails to maintain all
these vital functions, we have a solid argument for
starting dialysis therapy.
3/18/2013
Dr. Abrar Ali Katpar@1st Nephrology
Symposium & Workshop on World
Kidney Day at KKH-Hail.
5
Goals of dialysis
6.
K/DOQI
3/18/2013
Dr. Abrar Ali Katpar@1st Nephrology
Symposium & Workshop on World
Kidney Day at KKH-Hail.
6
GUIDELINE 1
When to Initiate Dialysis–Kt/Vurea Criterion (Opinion)
Unless certain conditions are met, patients should be advised to initiate some form of dialysis
when the weekly renal Kt/Vurea (Krt/Vurea) falls below 2.0. The conditions that may indicate
dialysis is not yet necessary even though the weekly Krt/Vurea is less than 2.0 are:
1. Stable or increased edema-free body weight. Supportive objective parameters for adequate
nutrition include a lean body mass >63%, subjective global assessment score indicative of
adequate nutrition and a serum albumin concentration in excess of the lower limit for the
lab, and stable or rising; and
2. Nutritional indications for the initiation of renal replacement therapy.
3. Complete absence of clinical signs or symptoms attributable to uremia.
A weekly Krt/Vurea of 2.0 approximates a kidney urea clearance of 7 mL/min and a kidney
creatinine clearance that varies between 9 to 14 mL/min/1.73 m2. Urea clearance should be
normalized to total body water (V) and creatinine clearance should be expressed per 1.73 m2 of
body surface area. The GFR, which is estimated by the arithmetic mean of the urea and
creatinine clearances, will be approximately 10.5 mL/min/1.73 m2 when the Krt/Vurea is
about 2.0.
7. 3/18/2013
Dr. Abrar Ali Katpar@1st Nephrology
Symposium & Workshop on World
Kidney Day at KKH-Hail.
7
Early Start of Dialysis: A Critical Review
Steven Rosansky*, Richard J. Glassock†, William F. Clark‡
Abstract
Summary In the US, patients who initiate dialysis “early” (at Modification of Diet in
Renal Disease estimated GFR [eGFR]> 10 ml/min per 1.73m2) account for over 50
percent of new dialysis starts. This trend to an early start is based on conventional
wisdoms regarding benefits of dialytic clearance, that albumin levels are nutritional
markers, and early dialytic therapy is justified to improve nutrition especially in
diabetics and that waiting until low levels of eGFRmay be dangerous. In order to
justify early dialysis treatment, the therapy must provide a morbidity, mortality, or
quality of life benefit. The current review examines whether early dialysis initiation
provides any of these benefits and whether the conventional wisdoms that have
promoted this early dialysis trend are valid. Utilizing this information and the
results of recent large observational studies and the randomized controlled
Initiating Dialysis Early and Late (IDEAL) study, we suggest that dialysis initiation
is justified at GFR levels of 5–9 ml/min/1.73m2, if accompanied by uremia
symptoms or fluid management issues.
8.
Intractable ECV overload
Hyperkalemia
Metabolic acidosis
Hyperphosphatemia
Hypercalcemia or hypocalcemia
Anemia
Neurological dysfunction (eg, neuropathy, encephalopathy)
Pleuritis or pericarditis
Otherwise unexplained decline in functioning or well-being
Gastrointestinal dysfunction (eg, nausea, vomiting, diarrhea,
gastroduodenitis)
Weight loss or other evidence of malnutrition
Hypertension.
3/18/2013
Dr. Abrar Ali Katpar@1st Nephrology
Symposium & Workshop on World
Kidney Day at KKH-Hail.
8
Complications That May Prompt Initiation of
Kidney Replacement Therapy.
9.
The key question is whether we have to start dialysis
prior to, or after the overt development of these
uremic signs and symptoms
1. The beneficial effects that dialysis can offer to the
pre-dialysis renal failure patient.
2. The potential complications of dialysis, and the
changes in the way of life that many patients have to
endure, are factors which should temper this
decision.
3/18/2013
Dr. Abrar Ali Katpar@1st Nephrology
Symposium & Workshop on World
Kidney Day at KKH-Hail.
9
When to Initiate??
10.
When to Initiate Dialysis : K t/V urea Criterion (Opinion)
patients should be advised to initiate some form of
dialysis when the weekly renal Kt/V urea < 2.0. Unless:
1. Stable or increased edema-free body weight.
2. No Nutritional indications
3. Complete absence of clinical signs or symptoms attributable
to uremia.
A weekly Kt/V urea of 2.0 approximates a kidney urea
clearance of 7 mL/min and a kidney creatinine clearance
that varies between 9 to 14 mL/min/1.73 m 2.
3/18/2013
Dr. Abrar Ali Katpar@1st Nephrology
Symposium & Workshop on World
Kidney Day at KKH-Hail.
10
KDOQI.. Timing of Therapy
11.
patients with chronic kidney failure (e.g, GFR < 15 to
20 ml/min) who are not undergoing maintenance
dialysis, if protein-energy malnutrition (PEM)
develops or persists despite vigorous attempts to
optimize protein and energy intake and there is no
apparent cause for malnutrition other than low
nutrient intake, initiation of maintenance dialysis or
a renal transplant is recommended (Opinion).
3/18/2013
Dr. Abrar Ali Katpar@1st Nephrology
Symposium & Workshop on World
Kidney Day at KKH-Hail.
11
KDOQI.. Timing of Therapy
12.
Timing of therapy: When patients reach stage 5 CKD
(estimated GFR < 15 mL/min/1.73 m2),
nephrologists should evaluate the benefits, risks, and
disadvantages of beginning kidney replacement
therapy. Particular clinical considerations and certain
characteristic complications of kidney failure may
prompt initiation of therapy before stage 5 (B)
AJKD VOL 48, NO 1, SUPPL 1, JULY 2006
3/18/2013
Dr. Abrar Ali Katpar@1st Nephrology
Symposium & Workshop on World
Kidney Day at KKH-Hail.
12
KDOQI.. Timing of Therapy
Second update of the Clinical Practice Guidelines (CPGs) &
Clinical Practice Recommendations (CPRs)
13.
3/18/2013
Dr. Abrar Ali Katpar@1st Nephrology
Symposium & Workshop on World
Kidney Day at KKH-Hail.
13
14.
Bonomini et al, 1985
Reported that an early start of dialysis was
associated with reduced mortality & morbidity.
Among a subset of patients who were subsequently
transplanted, there was a survival advantage for
those started dialysis early (n=50) vs later (n=96), as
well as less vascular calcification, bacterial
infection, dyslipidemia and hospitalization!
3/18/2013
Dr. Abrar Ali Katpar@1st Nephrology
Symposium & Workshop on World
Kidney Day at KKH-Hail.
14
Early initiation – Believers..
15.
CANUSA Study (McCusker et al 1996) PD
Significantly poorer survival for patients with lower levels
of renal function when starting dialysis
The mean creatinine clearance at the start of dialysis for all
patients was 38 L/wk (3.8 ml/min)
12 and 24 month survival for those with creatinine clearance
<38 L/wk at start of dialysis was 82.1% and 73.6%,
respectively, compared with 94.7% and 90.8%, respectively,
for those with creatinine clearance >38 L/wk.
In the CANUSA study, there was a survival advantage for
higher total (residual plus dialysis) Kt/V up to 2.0, and
possibly up to 2.3
3/18/2013
Dr. Abrar Ali Katpar@1st Nephrology
Symposium & Workshop on World
Kidney Day at KKH-Hail.
15
Early initiation – Believers..
16.
Tattersall et al. ( Am J Nephrol 15: 283 -2 89, 1995)
Prospective cohort study of 63 patients in 1991–92.
Demonstrated reduced survival in patients with less
residual renal function at start of dialysis, although
these patients were also significantly older and had
significantly more co-morbidity.
Hospitalization length of stay was greater among
those with residual Kt/V <1.05 at time of initiation of
dialysis.
3/18/2013
Dr. Abrar Ali Katpar@1st Nephrology
Symposium & Workshop on World
Kidney Day at KKH-Hail.
16
Early initiation – Believers..
17.
Schulman G and Hakim RM
Improving outcomes in chronic hemodialysis patients:
should dialysis be initiated earlier? Semin Dial 1996;
9(3):225-9
patients initiated on dialysis with a creatinine
clearance > 10 ml/min had an 88% 10- year survival
when compared to 55% in those initiated at a
creatinine clearance of < 10 ml/min (mean 4 ml/min)
3/18/2013
Dr. Abrar Ali Katpar@1st Nephrology
Symposium & Workshop on World
Kidney Day at KKH-Hail.
17
Early initiation – Believers..
18.
3/18/2013
Dr. Abrar Ali Katpar@1st Nephrology
Symposium & Workshop on World
Kidney Day at KKH-Hail.
18
Early initiation
However,
early initiation of dialysis expose
patients : complications of
dialysis, unnecessary lifestyle
restriction, potential increased
cost, patient fatigue.
No RCTs - Confounding influences
in other studies include referral
time bias, age, co-morbidity, patient
compliance and starting time bias.
Lead time bias.
Early initiation - skeptics - lead time bias
In the context of initiation of dialysis, lead-time bias refers to
the effect whereby measuring survival from the start of
dialysis increases apparent survival of those started with more
residual renal function i.e., earlier in the course of the
disease, than those who start dialysis with less residual renal
function
When to initiate dialysis: effect of proposed US guidelines on
survival.
Korevaar et al. Lancet 2001 Sep 29; 358(9287):1046-1050
In NECOSAD study (Korevaar et al.) estimated the effects of
lead-time bias on dialysis survival by using prediction
software based on the Finnish Cancer Registry
timely initiation - associated with a small survival benefit of 2.5
months
However, the extra time free of dialysis for “late starters ” was
only 4.1 months
This study suggested that any perceived survival benefit from
early start could be accounted for by lead-time
Early initiation - skeptics – QOL
(Korevaar et al 2002)
(Evaluation of DOQI guidelines: Early start of dialysis
treatment is not associated with better health-related
quality of life. Am J Kidney Dis 2002; 39:108- 1 15)
Prospective cohort study from Holland
38% of 237 incident dialysis patients commenced
dialysis late, as defined by the K/DOQI guidelines.
Compared with patients who have timely initiation,
the HRQOL among late starters was worse during the
first 6 months after initiation, but no different at 12
months
Early initiation does not prolong survival?
• Impact of timing of initiation of dialysis on mortality.
Beddhu et at. JASN 14: 2305-2312, 2003
• Post-hoc analysis of the MDRD study, comparing
early (predicted MDRD GFR>7.5 ml/min; N = 1,444)
with late (predicted GFR <7.5 ml/min); N =
1,476), higher MDRD GFR at initiation was associated
with an increased risk of death in multivariate Cox
model (hazard ratio 1.27 for each 5 ml/min increase)
• “ reflect an erroneous GFR estimation by MDRD
formula”
• Concluded that the data do not support early
initiation of dialysis
Early initiation of dialysis increases risk of mortality?
Kazmi et al – Am J Kidney Dis. 2005 Nov;46(5):887-96
undertook an evaluation of the impact of comorbidity
on the association between GFR at initiation and death
Results: greater GFR at initiation associated with a
greater risk for death in all populations
Patients in the general dialysis population who
initiated dialysis therapy at a GFR >10 mL/min/1.73
m2 had a 42% increased risk for death compared with
patients with a GFR < 5 mL/min/1.73 m2 at initiation
of dialysis therapy after adjusting for all covariates
Additional research required.
19.
(IDEAL) TRIAL
The Initiating Dialysis Early and Late
1. Enrollment, Randomization, and Follow-up.
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19
Definite answer?
20.
The data for time to the initiation of dialysis (Panel A) were censored at the time of
death, transplantation, or withdrawal of consent or at the time a patient transferred to a
nonparticipating hospital, emigrated, or could not be contacted. The curves for time to death
(Panel B) are truncated at 7 years of follow-up and a cumulative hazard of 60%.
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2. Kaplan–Meier Curves for Time to the Initiation
of Dialysis and for Time to Death.
21.
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Primary and Secondary Outcomes, Including Adverse Events
22.
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Effect of the Timing of Dialysis Initiation
in Subgroups
The forest plot shows the
hazard ratio (and 95%
confidence intervals) for
the primary outcome of
death from any cause,
with early initiation as
compared with late
initiation of dialysis,
according to each of the
prespecified subgroups.
The body-mass index
(BMI) is the weight in
kilograms divided by the
square of the height in
meters. GFR C–G denotes
glomerular filtration rate
estimated with the
Cockcroft–Gault equation,
and GFR MDRD the
glomerular filtration rate
estimated with the
Modification of Diet in
Renal Disease equation.
23.
Primary outcome = death from any cause.
Secondary outcomes=
cardiovascular events:
cardiovascular death,
nonfatal myocardial infarction,
nonfatal stroke,
transient ischemic attack,
new-onset angina
infectious events:
death or hospitalization due to any infection-related cause,
complications of dialysis :
temporary placement of an access catheter,
need for access revision,
infection at the access site,
fluid and electrolyte disorders requiring hospitalization,
additional dialysis.
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Dr. Abrar Ali Katpar@1st Nephrology
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Kidney Day at KKH-Hail.
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Study Outcomes
24.
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When to initiate dialysis?
Rosansky and colleagues[1] addresses the issue
of when is the appropriate time to start dialysis.
This study raises questions about the increasingly
common practice of an early start to dialysis.
The title of the paper appropriately is "Early Start of
Hemodialysis May Be Harmful."
The higher the GFR at the time dialysis was
started, the higher the subsequent mortality and, in this
study, first year mortality. Patients who started dialysis
with GFRs in the 5-10 mL/min range had substantially
lower mortality than those who started dialysis at each
successively higher level of GFR, including 10-15 mL/min
and over 15 mL/min.
25.
Adhere to best practice…….
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Dr. Abrar Ali Katpar@1st Nephrology
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26. AJKD VOL 48, NO 1, SUPPL 1, JULY 2006.
http://www.kidney.org/professionals/kdoqi/guid
elines_commentaries.cfm
http://ebookee.org/Nephrology-eBook-
Pack_1066049.html
http://www.expertconsultbook.com
http://patientsafetyauthority.org/ADVISORIES
https://www.nephropath.com
http://kidney.niddk.nih.gov/kudiseases/pubs/he
modialysisdose
http://www.medscape.org
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Dr. Abrar Ali Katpar@1st Nephrology
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References